The APA Commentary on ETHICS€¦ · 4/15/2016 1 THE APA COMMENTARY ON ETHICS Rebecca Weintraub...

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THE APA COMMENTARY ON ETHICSRebecca Weintraub Brendel MD, JD, Chair

April 16, 2016

© 2015 American Psychiatric Association. All rights reserved.

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DISCLOSURE

Employment

Massachusetts General Hospital

Harvard Medical School, Center for Bioethics

Director, Master of Bioethics Degree Program

Other

Expert Panel, Beacon Health Options

Royalties, Lexis Nexis, MA Guardianship Textbook

Councilor, Academy of Psychosomatic Medicine


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INTRODUCTION

The “Document”

Work began many years ago

Comprehensive educational document on ethics

Key Players and History

Essentially no work since 2008

Revive and revise, 2015

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BOT AD HOC WORKING GROUP

Rebecca Weintraub Brendel MD, JD – ChairpersonWade Myers MD – APA Ethics CommitteeCharles Dike MD – Chair, CT DB Ethics CommitteeHarold Ginzburg MD, JD – APA AssemblyRobert Weinstock MD – Council on Psychiatry and LawPhil Candilis MD – Corresponding MemberPaul Appelbaum MD – ConsultantLaura Roberts MD – ConsultantEzra Griffith MD – Consultant, Chair APA Ethics CommitteeStaff: Colleen Coyle – APA General CounselStaff: Shari Graham – APA Assistant General CounselStaff: ZhuoyinYang – Executive Assistant


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THE TASK: DETERMINING PURPOSE

People

Comprehensive document

What next?

History

Initial phone and in-person meetings

Goal = product, ambitious time line

Process important

Many stakeholders


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THE LANDSCAPE OF APA ETHICS

The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, 2013

Based on AMA Principles as of 2001

Address unique features of psychiatric practice

Guidance, not absolute, with revisions over time

Central document and guiding principles, but broad and hard to apply to day to day practice

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LANDSCAPE: OPINIONS

Opinions of the Ethics Committee on the Principles of Medical Ethics, 2014

Questions raised by APA members

Opinions prepared by APA Ethics Committee

Represent perspectives of the particular time written

Do not represent APA

Help members and DBs in understanding the principles

More specific, case-based guidance

Based on questions submitted, points in time


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LANDSCAPE AND UTILITY

Ethics Primer

Residents/ trainees and teachers of ethics

Last edition, 2001

Need for a comprehensive resource document

Practical guidance on major topics

Tools to manage ethical challenges

Based in and referenced to Principles


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COMMENTARY: PROCESS

Review of existing document

A lot changes in a decade

But not everything

Challenges in creating a new document

Timely and timeless (relatively)

Some, but maybe not so many, bright line rules

Providing tools, rationale, resources to engage challenges

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COMMENTARY: APPROACH

Practical approach

Rules and tools (skills)

Some situations have clear guidance

-- exploitation, boundaries

Others are more nuanced

-- involuntary treatment

Identify sources of principles and rules

What values are at stake?

AND

How can we think about them?


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KEY CONCEPTS

Role/ utility of identifying key ethical theory/ principles/ concepts at stake

Deontology, deon, gr. dutyConsequentialism, e.g. utilitarianismVirtue ethics, professional ethicsPrinciplism

AutonomyBeneficenceNon-maleficenceJustice

Be explicit about challenges: ethical dilemmas occur when important values are in tension


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OVERVIEW

Introduction and Principles

Ethical/ Professional Basis of Psychiatrist-Patient Relationship

Ethical/ Professional Practice

Ethical/ Professional Basis of Relationships with Colleagues

Other ethically important topics

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PSYCHIATRIST-PATIENT RELATIONSHIP

Duty to patient

-- autonomy, relationship by mutual consent, partnership

-- when does it start?

Competent Care

-- care within standard practice

-- innovation? subspecialization?

Overlapping roles/ dual agency

-- competing obligations are a reality


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ETHICAL/ PROFESSIONAL PRACTICE

Confidentiality

-- EMR, Rx database, limits

Informed Consent

-- based in respect for persons, ongoing process

Honesty/ Integrity

-- truthful and full as rule

Non-participation in Fraud

-- even when helps the patient?

Boundaries

-- many practice areas and models

Philanthropy

-- institutional vs. patient perspectives


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RELATIONSHIPS WITH COLLEAGUES

Consultation

Non-psychiatrists on teams

Supervision

Impairment and unethical conduct of colleagues

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OTHER ETHICALLY IMPORTANT TOPICS

Organized systems of care

Clinical innovation

End-of-life

Industry

Small communities

Technology

Public statements

Civil disobedience

Execution

Interrogations


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SELECTED TOPICS

Address three sections:

-- Managed Care

-- Execution

-- Internet

Themes

-- The world changes, how do we remain ethical?

-- How can we keep our practice in line with ethics?

-- and vice versa

-- How do we retain the identity of our profession (and our ethics) in the setting of change/ need


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SELECTED TOPICS

Managed Care

-- Practice constraints

-- Potential and actual conflicts

-- Psychiatrists in two broad categories:

-- Providing care to contracted patients

-- Working in systems of managed care

What’s at stake

-- Honesty

-- Patient as paramount

-- Competent care

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SYSTEMS OF CARE

Managed Care Accountable Care

Features of ACOs-- More than cost containment

Integrated systems of care--teams-- indirect forms of participation in care-- information-- financial risk

Ethical considerations-- Responsibility to patients? Non-patient members? Organization?-- How do roles of psychiatrists within ACOs affect ethics?

-- consultative participation-- Anticipate new models of care


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SYSTEMS OF CARE: ETHICS

Teams

-- professional responsibility – colleagues and patients

-- supervision

-- competent care

-- caution re relationship to patient if not seen/ balance

Integration

-- confidentiality

-- patient paramount

Financial considerations?

-- level of system vs. patient

Anticipate new care models


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SELECTED TOPICS

Execution

-- No direct participation

-- Competency to be executed – evaluation? Restoration?

-- Other phases of trial?

-- Respect for law?

Potential for role conflict

-- respect law (but advocate for change)

-- role clarity

-- avoid dual agency: respect for persons

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EXECUTION

What is direct participation?

Is it possible to separate roles of care from circumstance?

i.e. treating suffering

Is it necessary to view totality of circumstances?

i.e. wear blinders

Dual Agency vs. Robust Professionalism (Candilis, Martinez)

-- is awareness/ balancing possible?

-- how did we get here and why?

-- broad view incorporating nuance, motivation, stability


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SELECTED TOPICS

The Internet

-- Now includes information technology resources

-- Consultation required

Examples

-- Email Texting

-- Smartphones

-- Webpages/ Social Media

-- Apps, metadata

Challenges and Opportunity

-- Tension in new technology

THEN AND NOW …

• Paper charts

• Rotary phones

• Index Medicus

• EHRs and some paper records

• Cell phones

• Texting

• Email

• MyChart

• Google

• Online medical info

• Online ratings

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WHAT SHOULD ONE DO?

Opportunity for innovation

“Today’s problems were yesterday’s solutions”

Appreciate benefits AND potential pitfalls

Approach:-- Describe/ characterize the ‘activity’-- What core issues/ principles are at stake

ONLINE SOCIAL NETWORKING (2009)

• Employ existing frameworks for thinking about what role or purpose technology might serve

• Friendship with patients isn’t a customary part of physician – patient relationship

• Significant privacy concerns

• Access to information

Guseh J, Brendel R, Brendel D. J Med Ethics 2009; 35: 584-586

RECOMMENDATIONS 2009

• Avoid entering into dual relationships

• Manage any info about patients carefully –including info on social media

• Restraint in disclosing personal information

• Know about privacy settings

• Lifelong learning includes technology

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RECOMMENDATIONS 2013

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards

Employs risk-benefit approach

Ann Intern Med 2013: 158:620 - 627

EXAMPLES

Communications (email, text, IM)-- benefits: access, quick turnaround-- risks: confidentiality, impersonal, ambiguity-- strategies: guidelines, cont’ in-person contact

Social media sites to gather information-- benefits: observe and counsel patients-- risks: threaten trust in relationship-- strategies: clarity of intent, implications for care

Ann Intern Med 2013: 158:620 - 627

EXAMPLES

• Physician posting of personal information on social media sites– Benefits: networking and communication– Risks: blurring of professional and personal boundaries;

» Representation of the individual» Representation of the profession

– Strategies: » Maintain separate personas» Scrutinize material available for public consumption

Ann Intern Med 2013: 158:620 - 627

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GUIDING PRINCIPLE (I)

• Physicians must consistently apply ethical principles for preserving the doctor-patient relationship

• Core responsibilities:

– confidentiality

– privacy

– respect for persons

THE RELATIONSHIP, IN PRACTICE

• Patient – Physician Relationship is Fiduciary

• To Friend or Not To Friend – Or Google

– Or LinkedIn

• Confidentiality– Patient may breach; MD shouldn’t

• Medicine and Society– Physicians are allowed to have a life

– What are the limits?

GUIDING PRINCIPLE (II)

• Boundaries can blur online

• Physicians should:

– Keep the professional and the personal separate

AND

– Act professionally in both

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BOUNDARIES IN PRACTICE

• Separate online sites or identities for separate roles

• Boundaries, privacy settings

• Training physicians in training

• What about connecting with students, residents, staff?

– Is Facebook different than LinkedIn?

GUIDING PRINCIPLE (III)

• Role Clarity:

– Email or other electronic communication – only in established patient physician relationship

• Respect for persons

– Use of online media only with patient consent

• Competent care

– Document patient care communication in medical record

COMMUNICATION IN PRACTICE

• What’s appropriate in e-mail? Turnaround time?

• Encryption and secure accounts

• Legal requirements vary by state

• Texting isn’t secure

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GUIDING PRINCIPLES (IV-V)

• Periodically “self-audit” accuracy of information about yourself online

– physician-ranking websites

– other sources online

• Online postings may have future implications for professional life

ANALYSIS

• Many of the issues posed by technological advances are old wines in new bottles

• Framework to think about using technology– Identify core professional values and responsibilities– Balance between potential benefits and risks

• Must understand the innovation

– Be clear about what you are doing and why

• Know your resources/ constraints– Colleagues– Professional resources – be aware of guidelines/

recommendations– Law/ regulation– Ethics


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SUMMARY

Place and use for a comprehensive resource document

Challenges will continue to grow and change

Goal is a relevant document that is specific enough to be useful but general enough to withstand time

Importance of underlying principles and theoryDeliberative psychiatristRobust professionalismMany (all?) innovations can be addressed with existing principles

-- If not, what’s the problem – identify clearly

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RESOURCES

APA Commentary on Ethics in Practice: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Ethics/APA-Commentary-on-Ethics-in-Practice.pdf.

Additional references available upon request

https://www.psychiatry.org/File Library/Psychiatrists/Practice/Ethics/APA-Commentary-on-Ethics-in-Practice.pdf

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